Webinar Details

Ligature Risks: Ensuring Compliance with the CMS Hospital CoPs and TJC Requirements 2021

24X7 Club

Video Audio

Key Point

Recall that CMS now has two tag numbers that set forth requirements to prevent ligature and suicide risks for patients with suicidal ideations Discuss that the Joint Commission has requirements for hospitals to follow to prevent patients from self-harm including hanging or strangulation Describe that CMS recommends education in orientation, when policies change and every two years Recall that CMS has proposed guidelines

BRIAN L TUTTLE

Published: 2021-10-06

BRIAN L TUTTLE

Education:- Certified HIPAA Professional

Brian L Tuttle, CPHIT, CHP, CBRA, Net+, A+, CCNA, MCP is a Certified Professional in Health IT (CPHIT), Certified HIPAA Professional (CHP), Certified HIPAA Administrator (CHA), Certified Business Resilience Auditor (CBRA), Certified Information Systems Security Professional (CISSP) with over 18 years' experience in Health IT and Compliance Consulting. With vast experience in health IT systems (i.e. practice management, EHR systems, imaging, transcription, medical messaging, etc.) as well as over 18 years’ experience in standard Health IT with multiple certifications and hands-on knowledge, Brian serves as compliance consultant and has conducted onsite and remote risk assessments for over 1000 medical practices, hospitals, health departments, insurance plans, and business associates throughout the United States.

Description:

This is a hot area and there is a lot of survey activity around the prevention of suicidal patients from harm or strangulation. The Joint Commission announced that this is one of the four top areas of focus and their data shows that hospitals are receiving many RFIs in this area. The Centers for Medicare and Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self-harm from patients that are suicidal. A 13-page memo was issued and the hospital manual was amended. Any hospital that received Medicare, which is most hospitals in America, must implement these changes for all patients. This webinar will also discuss the CMS proposed 15-page guidelines changes for 2020.

CMS amends tag numbers 144 inpatient rights and tag 701 in facility services. This discusses what units need to be ligature resistant. It covers what patient assessments must be done and what should be in the environmental assessments. It discusses education and policy and procedure requirements. If you have a highly suicidal patient and the room is not ligature resistant do you have a 1:1 sitter? Hospitals that do not will need to change their policy and process and budget for this.

Joint Commission has 16 requirements to ensure compliance with their standards. These will discuss in detail and include psych hospital, behavior health units, general acute care inpatient units, outpatient units, and emergency departments. The zero suicide campaign will be discussed. The TJC sentinel event alerts on suicide, NPSG 15 and final changes July 1, 2019, and Frequently Asked Question (FAQ) on ligature risk will be covered. This includes one related to whether video monitoring is ever allowed. Again, the Joint Commission announced that this is one of four areas of focus so hospitals need to have this issue on their radar screen and be prepared.

Resources will be provided. Tools to assess patients to determine if they have suicidal ideations will be included.

Objectives:-

Recall that CMS now has two tag numbers that set forth requirements to prevent ligature and suicide risks for patients with suicidal ideations
Discuss that the Joint Commission has requirements for hospitals to follow to prevent patients from self-harm including hanging or strangulation
Describe that CMS recommends education in orientation, when policies change and every two years
Recall that CMS has proposed guidelines

Detailed Outline:-

CMS Hospital Ligature Risks

Introduction
15 pages proposed guidelines for 2020
13-page memo and manual updated
Amends tag 144 and 701
Deficiency reports
Suicide 10th leading cause of death
What is a ligature risk? CMS definition
Anchor points and examples
Policy and procedure requirements
Education recommendations
Competency requirements
Patient assessment
Environmental assessment
Correction of environmental risk
Design guide for creating safe rooms
Things to do to reduce ligature risk
Documentation requirements
VA mental health guide and checklist
When are sitters or 1:1 observers required?
Ligature resistant requirements

Joint Commission

13 requirements to prevent suicide
3 requirements for outpatient and residential treatment centers
Recommendation for psych unit, psych hospital, and general acute care settings including emergency departments
Sentinel event reduction doors and soft suicide prevention doors
Ceilings, beds, and toilets
Shower curtains
SAFER matrix and when at risk for getting RFI
EC.02.06.01 EP 1 requirements
Dedicated versus non-dedicated spaces
Suicide risk reduction
Zero suicide campaign
TJC ligature risk FAQs
TJC sentinel event alerts on suicide and SEA 56
NPSG 15 changes July 1, 2019

Resources and tools of the trade

Suicide prevention resource center
VA/DoD Clinical practice guidelines
Suicide prevention guidelines for training
Design guide for the built environment of behavioral health facilities
Patient health questionnaire PHQ-9 and 3
ED-SAFE screeners
Patient safety secondary screener
ED” Suicide Behaviors Questionnaire SBQ-R
Environmental Assessment
C-SSRS Columbia Suicide Severity Rating Scale
SAFE-T Assessment
Suicide Prevention Decision Support Tool and more
NY patient safety standards guidelines

Who Should Attend?

All staff, nurses, physicians, and providers on the hospital behavioral health unit
All staff, nurses, physicians, and providers at Psychiatric hospitals
All staff, nurses, physicians, and providers in hospital emergency departments
All staff, nurses, physicians, and providers on hospital units where suicidal patients are taken care of such as ICU, medical-surgical units, OB and post-partum, and outpatient areas
All hospital risk managers
Hospital legal counsel
Patient safety officer
CEO, COO, CNO, and nurse supervisors
Chief medical officers
Director of maintenance and facility services
Biomedical engineering
Materials management
Environmental Services
Security
Director in charge of the environment of care requirements and staff
Quality improvement coordinator
Compliance officer
Director of Regulatory Affairs
Board members
Nurse educator
Clinic and outpatient managers
All department directors/nurse managers such as ED, ICU, CCU, Med-Surg managers, outpatient, etc.
Anyone who is responsible to ensure compliance with the CMS hospital conditions of participation and the Joint Commission standards